- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.08 / $1,685.28 / $1,778.37
| Professional | | $1,192.08 | $1,685.28 | $1,778.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.98 / $1,854.09 / $2,679.66
| Professional | | $1,575.98 | $1,854.09 | $2,679.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.25 / $2,014.29 / $3,692.50
| Professional | | $1,682.25 | $2,014.29 | $3,692.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.94 / $2,002.23 / $3,365.08
| Professional | | $1,458.94 | $2,002.23 | $3,365.08 |